"Injuries need balance to heal."

Reflex sympathetic dystrophy (RSD)—recently renamed complex regional pain syndrome types I and II—is a documented condition described in the literature as a pain syndrome occurring as a result of trauma to a body part. Repetitive strain injuries have been described as injuries that at least partially involve microtrauma to soft tissue. In a number of cases patients with RSI have slowly developed RSD, which has been neglected in the literature. I have recently been introduced to the possibility that many RSI patients have "mild" or "early" RSD, and I want to alert other clinicians as well as patients.

Traditionally, physicians have diagnosed RSD when certain documented medical criteria have been met. In order for the diagnosis of "probable RSD" to be made, the patient would need to exhibit five or more of the following criteria as indicated in the literature by Colton and Fallat (1966):

Allodynia (perception of pain from a stimulus that is normally not noxious) or hyperpathia (an exaggerated response to painful stimuli)

According to the literature, patients with fewer than three of the above symptoms are considered not to have RSD. The typical medical model would test for other possible pathologies with similar symptoms, such as rheumatoid arthritis. When these tests all come back negative, many physicians conclude the patient has neuropathic pain of unknown origin. I have worked with many patients diagnosed with RSI and related conditions (e.g., carpal and cubital tunnel syndromes, thoracic outlet syndrome and related diagnoses, including brachial plexopathy). As these disorders have nerve-related origins, one would expect to see neurological symptoms manifested, such as burning or allodynia. In this article I discuss some of my recent clinical observations that may benefit patients who present with any of the symptoms on the above list.

Recently, several physicians with whom I work decided to try treating people with fewer than three of the symptoms on the list as if they have "early stage RSD" or "mild RSD," after first ruling out other possible causes. In the past, when physicians ruled out other possible causes and when all tests came back negative, they diagnosed neuropathic pain and sent patients to physical therapy for conservative pain management. Although this approach has proven effective, it is a long process that, in some cases, has required years of treatment. With the recent increase in the number of patients being treated for "early RSD" (those who manifest three or fewer symptoms from the list), the recovery time has improved dramatically. I have seen symptoms of burning pain—which typically have taken months to resolve with very diligent retraining and activity modification—disappear in a matter of weeks. This is a significant breakthrough in patient treatment, and I encourage anyone who exhibits three or fewer of the above symptoms to discuss this with his or her doctor. The treatment includes various types and levels of pharmacological management, among them Neurontin, Tegretal, alpha and beta-blockers, clonidine, antidepressants, and anti-inflammatories, in different doses with varying combinations of each possible. Patients who have tried some of these medications but not at a high enough dose to be effective have shown improvement with the same medications at higher doses. Some patients I have treated did not notice improvement until they reached 2400 mg. of Neurontin, for example; others did very well on 600 mg. Some patients responded to a combination of Neurontin with an antidepressant. A pain management physician best makes these pharmacological decisions with experience in treating RSD/RSI. Non-physician health care professionals can neither diagnose illness nor prescribe medications. However, we can make clinical comparisons between patients we treat and make suggestions to physicians based on the clinical findings.

Many patients have expressed concern about taking a medication that will decrease recognition of their pain as a warning signal. These medications interfere with the abnormal pain response, defined usually as allodynia, hyperpathia, and/or summation (persistent or increased pain after repeated stimuli), which was triggered by the injury. This is different than "masking" pain with pain medication. I must also caution that this medication does not eliminate symptoms if a patient attempts to increase activity too quickly or too much. Most RSI patients need to develop activity modification as a lifestyle change; the medications do not replace the need to continue with this. They can, however, allow someone to get through activities of daily living, such as showering and dressing, with fewer or no symptoms. They can also allow people who are still working to perform moderate amounts of repetitive activities without increased symptoms. This does not mean they are hurting themselves without knowing it because they are unable to feel it, but rather that the prior pain response was abnormally exaggerated.

A recent observation about patients with a diagnosis of probable "early stage RSD" deals with interpretation of the literature. Documentation supports the view that RSD is somehow triggered by an injury that is followed by a period of immobility. In treatment for RSD it is imperative to get people to increase movement. I have noticed, clinically, that people who appear to have "early stage RSD" may attempt too much rest in order to avoid flare-ups of lingering pain. The pathology process may interpret this increased rest as immobility, which can then actually cause the pathology to progress to a more advanced stage of the disorder. This is an important consideration in treatment: to encourage people who may not realize they have RSD to move as much as possible without moving too much and actually causing flare-ups (some increased symptoms may be unavoidable; as long as they do not last long it is not clinically indicated as harmful). This can be a difficult task, as there are many variables involved with the activity?pain relationship and different thresholds to pain and activity on different days. Recently I have started to ask all patients to avoid too much rest, even if this means they hover at the threshold of irritation with occasional increased mild symptoms. I have also requested that they actively move all body joints through full range of motion (ROM) at least once a day. The rest of the treatment approach is similar to that for RSI patients without signs of early RSD. A summary of the treatment approach for RSI that I have found beneficial for patients is as follows:

Shared Aspects of RSD/RSI Treatment

Stretching tight muscles.

Strengthening weakened/stretched posterior thoracic postural muscles slowly?starting with active range of motion (AROM) and building to small weights when compensatory patterns are eliminated.

Reintegration of large proximal muscles into upper extremity activities, including decreasing compensatory motor patterns to the point of potentially reorganizing old movement patterns, such as:

Upper traps overrecruited for many arm movements;

Scalenes overrecruited for breathing;

Forearm flexors overrecruited for hand-intrinsic muscles.

Slow, structured reintegration of irritating activities—work and non-work—to include timing all activities that stimulate symptoms or increase symptoms, stopping before the onset of symptoms.

Myofascial release/deep tissue work (physical therapy/occupational therapy). For RSI, this is a temporary measure designed to help increase circulation and improve flexibility during initial phases of treatment protocol. For "mild" RSD, the increased proprioceptive input (feedback from the brain about position of joints) from stimulation of pressure-sensitive receptors in tissue may help to decrease RSD symptoms.

Complementary treatments to augment rehabilitation, decrease pain, and increase circulation. Patients must be aware of their own limitations and continue to modify activities to prevent increased symptoms. These may include:

Breathing/relaxation training

Meditation

Acupuncture

Medications, if applicable

Biofeedback

Yoga

Tai chi

Psychological intervention

Extra massage therapy (especially for whole-back?upper and lower?myofascial flexibility, and improvement of impaired circulation?a temporary measure designed to assist mobility exercises and stretches during initial phases of treatment)

In summary, the incidence of RSD in RSI may be much higher than is recognized at present. All patients need to be actively involved in their treatment. Patients cannot completely depend on a doctor to accurately diagnose and treat them. Doctors who specialize in RSI treatment are preferred, as they will be more informed about new treatment modalities. Keeping in touch with other patients and questioning them about their treatments can be helpful, if you discuss these treatments with your doctor.